被动抬腿试验评价感染性休克患者容量反应性的价值

Passive leg raising predicts volume responsiveness in patients with septic shock

目的 探讨被动抬腿试验（PLR）预测感染性休克患者容量反应性的价值.方法 2009年6月至2010年5月,20例感染性休克患者纳入研究.采用脉搏指示连续心输出量持续监测患者在基础状态、PLR前后的血流动力学变化,PLR后稳定10min行补液试验（生理盐水250 ml于10 min内静脉滴注）,监测补液试验前后血流动力学的变化.以补液试验后每搏量（SV）增加值（△SV）≥10%为容量反应组,否则为无反应组.评价PLR前后SV的变化（PLR-△SV）和脉压（PP）的变化（PLR-△PP）预测容量反应性的价值.结果 20例患者共行46次PLR和补液试验,其中反应组15例次,无反应组31例次.反应组PLR后SV较之前明显增加[（76±19）ml比（65±18）ml,P＜0.05],PLR后PP较之前显著增加[（73±20）mmHg比（62±20）mmHg（1 mmHg=0.133 kPa）,P＜0.05];无反应组PLR前、后SV和PP均无明显变化（P＞0.05）.PLR-△SV、PLR-△PP与补液试验后△SV呈正相关（r=0.51,P=0.001;r=0.45,P=0.006）,基础中心静脉压（CVP）与补液试验后△SV无相关性（P＞0.05）.PLR-△SV、PLR-△PP和每搏量变异度（SVV）预测容量反应性的ROC曲线下面积分别为0.846、0.791和0.708.以PLR-△SV≥12.5%评价容量反应性,灵敏度为80.0%,特异度为93.5%;以PLR-△PP≥9.5%评价容量反应性,灵敏度为73.3%,特异度为83.9%.结论 PLR-△SV和PLR-△PP可用于评估感染性休克患者的容量反应性,预测价值高于CVP和SVV,可作为指导容量治疗的指标.

bjective To evaluate the hemodynamic response to passive leg raising （PLR）indicates fluid responsiveness in patients with septic shock. Methods Twenty patients with septic shock,considered for fluid challenge（FC）, were enrolled in the study from June 2009 to May 2010. Hemodynamic changes were determined by pulse-contour derived cardiac index at baseline, before and after PLR, return to baseline for 10 min, before and after fluid challenge （250 ml saline for 10 min）. An increase of SV after fluid challenge（FC-△SV）≥10% were defined responders. Results Twenty patients with septic shock were included in the study. PLR and fluid challenge were performed 46 instances, among which 15 instances were defined as response group. SV and pulse pressure induced by PLR（PLR-△SV and PLR-△PP） were increased significantly in response group[（76±19）ml vs. （65±18）ml, （73 ±20） mmHg vs. （62 ±20）mmHg （1 mmHg=0.133 kPa）, P〈0.05], while in nonresponse group there were no significant change.PLR-△SV and PLR-△PP were correlated with FC-△SV （r=0.51,P=0.001; r=0.45, P=0.006）,central venous pressure （CVP） were irrelated with FC-△SV. Area under curve （AUC） for PLR-△SV, PLR△PP and stroke volume variation（SVV） were 0. 846, 0.791 and 0.708. PLR-△SV≥12. 5% predicted fluid responsiveness with sensitivity of 80% and specificity of 93.5%. PLR-△PP ≥9.5% predicted fluid responsiveness with sensitivity of 73.3% and specificity of 83.9%. Conclusions PLR-△SV and PLR-△PP can predict fluid responsiveness in patients with septic shock. PLR-△SV and PLR-△PP have a greater ability in predicting volume responsiveness than CVP and SVV.